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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1310_Библиотеки_им_академика_М_И_Перельмана.pdf
Laparoscopic Hemihepatectomy for Hepatocellular Carcinoma
Go Wakabayashi
Case Presentation
A 62-year-old man presented to his primary physician with a complaint of
abdominal pain. Past history was hepatitis B infection and it was to be treated.
Physical examination revealed a tender upper abdominal pain. The serum
alpha-fetoprotein (AFP) level was 118.5 ng/mL, and PIVKA-II was 820 mAU/mL.
Computed tomography (CT) evaluation revealed the images presented in Fig. 7.1,
and magnetic resonance imaging (MRI) is presented in Fig. 7.2.
Diagnosis and Assessment
7
Our patient demonstrated common presentation of advanced HCC. HCC is the most
frequent primary malignancy of the liver and one of the most common cancers in
the world. Advanced HCC is associated with clinical manifest ations of abdominal
pain, weight loss, jaundice, hepatosplenom egaly, ascites, deranged liver function
tests (LFTs), and elevated AFP [1]. We report here a patient with symptomatic
advanced HCC, normal LFTs, and elevated AFP values. Protein induced by vitamin
K absence or antagonist II (PIVKA-II) is also used as a diagnostic marker for HCC.
The use of these two complementary markers (AFP and PIVKA-II) appears to be
useful in the diagnosis of HCC. The frequencies of intrahepatic metastasis, portal
vein tumor thrombus, hepatic vein tumor thrombus, and capsular infiltration are
significantly higher in patients with positive PIVKA-II than in those with
G. Wakabayashi (&)
Ageo Central General Hospital, 1-10-10 Kashiwaza,
Ageo 362-8588, Japan
e-mail: gowaka@ach.or.jp
© Springer International Publishing AG 2017
T.M. Pawlik et al. (eds.), Case-Based Lessons in the Management of Complex
Hepato-Pancreato-Biliary Surgery, DOI 10.1007/978-3-319-50868-9_7
85
86 G. Wakabayashi
Fig. 7.1 Computed tomography imaging. a Arterial phase of multiple nodules; b arterial phase of
diffuse area staining with bile duct dilatation; c delayed phase of washed-out area; d coronal view
of arterial phase
negative-PIVKA-II. Therefore, PIVKA-II is one of the risk factors for recurrence of
HCC after hepatectomy [2].
Diffuse-type HCC has been considered as an extensive and infiltrative tumor with
poorly defined margins, frequently accompanied by portal venous tumor thrombosis
and high level of AFP. Preoperative images of our patient showed small infiltrative
diffuse-type HCC in segments II, III, IV (Fig. 7.1 ) and ill-defined lesions on segment
IV with intermediate signal intensity and heterogeneous post-gadolinium enhancement (Fig. 7.2).
Assessment for the future-remnant liver function is the most important step to
prevent postoperative liver failure. The Child-Pugh score consists of five clinical
features and is used to assess the prognosis of chronic liver disease and cirrhosis. The
score is also used to determine hepatic reserve for liver resection. The score considers five factors, three of which assess the synthetic function of the liver (i.e., total
7 Laparoscopic Hemihepatectomy for Hepatocellular Carcinoma 87
Fig. 7.2 Magnetic resonance imaging. Ill-defined lesions on segment IV with intermediate signal
intensity and heterogeneous post-gadolinium
bilirubin level , serum albumin, and international normalized ratio, or INR) and two
of which are based on clinical assessment (i.e., degree of ascites and degree of
hepatic encephalopathy). Moreover, indocyanine green (ICG) clearance is one of the
most reliable and easy-to-use tests for the preoperative dynamic assessment of liver
function for resectability [3]. According to the decision tree that we use (Fig. 7.3),
key points are: (1) contraindication to hepatic resection in presence of uncontrolled
ascites or serum bilirubin > 1.9 mg/dL; (2) minor resections possible with serum
bilirubin ranging between 1 and 1.9 mg/dL, the lower the bilirubin level, the larger
the resection; and (3) according to ICGR15 intervals different types of hepatic
resection possible in case of serum bilirubin < 1.1 mg/dL and no ascites [3].
Our patient was diagnosed as advanced HCC with possible infiltration to portal
veins in the left hemi-liver. Small infiltrative diffuse-type HCC was confined in the
left hemi-liver and the Child-Pugh score with ICGR15 allowed the left hemihepatectomy to remove all these HCC nodules.
88 G. Wakabayashi
Fig. 7.3 Treatment algorithm for hepatectomy. Extent of hepatectomy in cirrhotic patients
according to liver functional reserve. ICGR15 Indocyanine green retention ratio at 15 min.
Reprinted from De Gasperi A, Mazza E, Prosperi M. Indocyanine green kinetics to assess liver
function: Ready for a clinical dynamic assessment in major liver surgery? World J Hepatol.
2016 Mar 8;8(7):355–67; with permission from Baishideng Publishing Group Inc.
Technical Pearls
1. Precise parenchymal transection is the key to perform high-quality LLR.
2. Expose MHV to keep transection plane and to avoid hepatic vein injury.
3. DO NOT touch tumors to avoid dissemination.
4. Isolate the tumor bearing area by inflow occlusion with outflow closure
before manipulation.
Management
According to the BCLC algorithm, our patient is defined as stage B with intermediate HCC or stage C with advanced HCC, and resection is not recommended in
either stages. The standard treatments are TACE or Sorafenib [1]. However, if
hepatic reserve is preserved, we choose hepatectomy to remove all HCC with or
without portal vein thrombus even in BCLC stage B/C patients. Resection will
always give better effect on prognosis with better quality of life, if it is done safely.
We conducted a multi-institutional study using propensity score matching to
compare the perioperative and long-term outcomes of LLR to OLR for HCC [4].
The study clearly showed clinical benefits of decreased estimated blood loss,
shorter median length of stay, and less postoperative morbidity (6.7% vs. 13.0%)
comparing LLR to OLR with comparable oncologic outcomes for HCC. With
median follow-up of 47 months for LLR and 52 months for OLR, there were no
7 Laparoscopic Hemihepatectomy for Hepatocellular Carcinoma 89
differences in 1-, 2-, and 5-year disease-free or overall survival between the matched groups. Conversion from LLR to OLR or hybrid/hand-assisted procedure
occurred in 25 of 387 (6.5%) patients [4].
LLR started with partial resection and left lateral sectionectomy in early 1990s
[5–8]. The first formal laparoscopic hemihepatectomy was reported in 1998, using
the pure lapar oscopic method for left hepatectomies and the laparoscopy-assisted
method for right hepatectomies [9]. After the laparoscopic left lateral sectionectomy
became the standard of care for resection of lesions located in segments II and III,
the laparoscopic left hemihepatectomy has also become a standard of care in expert
hands [10, 11]. The surgical techniques for laparoscopic major hepatectomy include
pure laparoscopic, hand-assisted laparoscopic, and laparoscopy-assisted methods
[7, 12, 13]. Laparoscopic major hepatectomy is an innovative procedure that is still
in the exploration phase [14]. Although new surgical techniques have learning
curves, safety should be maintained from the onset [15]. We recommended at the
second consensus that laparoscopic major hepatectomy should continue to be
introduced cautiously [14].
Alternative left hepatectomy in minimally invasive way is laparoscopyassisted/hybrid or hand-assisted procedure [16]. In the pure laparoscopic procedure, the entire resection is completed through laparoscopic ports. Hand-assisted
laparoscopy was defined as the elective placement of a hand port during laparoscopic liver resection, to facilitate the procedure; and this technique is frequently
called hand-assisted laparoscopic surgery (HALS). The hybrid technique is started
as a pure or hand-assisted laparoscopic procedure, but the resection is performed
through a mini-laparotomy incision. The hybrid technique is also frequently called
the “laparoscopy-assisted” method. It is clear that HALS and the hybrid technique
may overcome certain difficulties associated with pure lapar oscopy, and may be less
invasive than a traditional open laparotomy [16]. It is not clear that these minimally
invasive liver resections would improve outcomes in patients with cirrhosis.
According to our experience, it appears that LLR for selected HCC patients with
cirrhosis is a feasible and promising procedure that is associated with less blood
loss and fewer postoperative complications, especially the incidence of postoperative ascites. Further investigations are clearly warranted in this field [17].
Alternative Approaches
1. BCLC stage B or C HCC can be resected with R0 margin
2. Laparoscopy-assisted/hybrid or hand-assisted procedure are alternative
way to perform left hemihepatectomy
3. HALS and the hybrid technique may overcome certain difficulties associated with pure laparoscopy.
90 G. Wakabayashi
Outcome
We chose to perform pure laparoscopic left hemihepatectomy on this patient. In our
standardized LLR for left side liver, patients are placed in head-up supine position
with legs closed, and the operator stands on the right side of patients [17]. A trocar
for a laparoscope is inserted from the umbilical area to induce CO
toneum (10–12 mm Hg). Trocar placement is always the same as shown in Fig. 7.4.
The operative procedures included : (1) cholecystectomy, (2) division of the left
portal branch and the left hepatic artery, (3) division of the left hepatic vein (LHV),
(4) parenchymal transection with exposure of the middle hepatic vein (MHV), and
(5) removal of the resected left hemi-liver through supra-pubic incision. It is
important to close LHV earlier to avoid tumor cells dissemination during manipulation of the left liver. We perform precise parenchymal transection under intermittent Pringle maneuver with slightly increased pneumoperitoneal pressure up to
12 mmHg. We use laparosonic coagulating shears for superficial parenchymal
transection, and an ultrasonic dissector (CUSA Excel; Integra Lifesciences Corp.,
New Jersey, U.S.) for deeper parenchy mal transection with exposure of MHV.
Intraoperative images are shown in Figs. 7.5 and 7.6. Operative outcomes, pathological TNM staging, and postoperative course are summarized in Table 7.1. The
resected left hemi-liver and its cut surface are shown in Fig. 7.7.
Fig. 7.4 Trocar position and
retrieval site. All trocars are
12 mm. Laparoscope is
inserted through umbilicus.
The resected specimen is
retrieved through supra-pubic
incision
pneumoperi-
2
7 Laparoscopic Hemihepatectomy for Hepatocellular Carcinoma 91
Fig. 7.5 Intraoperative view 1. a Multiple nodules are confined in the left liver; b superficial
parenchymal transection with laparosonic coagulating shears along the demarcation line produced
after inflow occlusion of the left hemi-liver; c demarcation line with superficial parenchymal
transection; d division of the left hepatic artery (LHA) and clipping of the left portal vein (LPV)
Fig. 7.6 Intraoperative view 2. a Division of the left hepatic vein (LHV) with an automatic
stapler; b exposure of the middle hepatic vein (MHV) with an ultrasonic dissector over the hilar
plate; c MHV is exposed and the hepatic vein from segment IV (V4) is divided; d final aspect of
the cut surface of the right hemi-liver with exposed MHV, the stump of LHV, the stump of LHA,
and the stump of LPV
92 G. Wakabayashi
Table 7.1 Summary data
Patient: 62y/o, Male, Hepatitis B virus infection
Preoperative assessments:
Child-Pugh Score: Class A (5 points), Bilirubin 0.6 mg/dL, Albumin 4.1 g/dL,
Prothrombin time 86%, No ascites, No Encephalopathy
ICGR15: 4%
Tumor Markers: AFP 118.5 ng/mL, PIVKA-II 820 mAU/mL,
CEA 1.2 ng/mL, CA19-9 6U/mL
Operative records: Pure Laparoscopic Left Hemihepatectomy (S2, 3, 4)
Operative Time: 358 min
Estimated Blood Loss: 290 ml
Pringle Maneuver: 5 times (15 min clamp followed by 5 min
reperfusion), total ischemic time 73 min
Resected Liver Weight: 396 g
Pathological TNM staging: Multiple nodules with diffuse spread, Maximal size 5 cm,
Microscopic invasions to the second bifurcation of portal
veins, bile ducts, and peripheral hepatic veins,
Stage 2 liver fibrosis (F2), Ishak staging scale 3
(F0 by AJCC/UICC), Negative surgical margin
AJCC/UICC TNM stage: T3aN0M0, Stage IIIA
LCSGJ TNM stage: T4N0M0, Stage IVA
Postoperative course: No complication, Diet started on 1POD,
Drain removed on 2POD, Discharged on 6POD,
No recurrence at 1POY
AFP alpha-fetoprotein; PIVKA-II protein induced by vitamin K absence or antagonist II; CEA
Carcinoembryonic antigen; CA-19-9 carbohydrate antigen 19-9; TNM Tumor-Node-Metastasis;
AJCC American Joint Committee on Cancer; UICC International Union Against Cancer; LCSGJ
The Liver Cancer Study Group of Japan
Clinical Pearls
1. Diffuse-type HCC confined to the left liver was totally resected by pure
laparoscopic procedure.
2. LLR is associated with decreased estimated blood loss, shorter median
length of stay, and less postoperative morbidity compared to OLR with
comparable oncologic outcomes for HCC.
3. High-quality LLR is needed to treat advanced HCC with precise
parenchymal transection and with oncological concerns.
4. Laparoscopic major hepatectomy should be introduced cautiously.
7 Laparoscopic Hemihepatectomy for Hepatocellular Carcinoma 93
Fig. 7.7 The resected left hemi-liver with its cut surface. a Whole resected left liver b Its cut
surface
References
1. Forner A, Llovet JM, Bruix J. Hepatocellular carcinoma. Lancet. 2012;379(9822):1245–55.
2. Suehiro T, Sugimachi K, Matsumata T, Itasaka H, Taketomi A, Maeda T. Protein induced by
vitamin K absence or antagonist II as a prognostic marker in hepatocellular carcinoma.
Comparison with alpha-fetoprotein. Cancer. 1994;73(10):2464–71.
3. De Gasperi A, Mazza E, Prosperi M. Indocyanine green kinetics to assess liver function:
ready for a clinical dynamic assessment in major liver surgery? World J Hepatol. 2016;8
(7):355–67.
4. Takahara T, Wakabayashi G, Beppu T, Aihara A, Hasegawa K, Gotohda N, et al. Long-term
and perioperative outcomes of laparoscopic versus open liver resection for hepatocellular
carcinoma with propensity score matching: a multi-institutional Japanese study. J Hepatobiliary Pancreat Sci. 2015;22(10):721–7.
94 G. Wakabayashi
5. Wakabayashi G. Laparoscopic liver resection: how far can we go? J Hepatobiliary Pancreat
Surg. 2009;16(4):403–4.
6. Sasaki A, Nitta H, Otsuka K, Takahara T, Nishizuka S, Wakabayashi G. Ten-year experience
of totally laparoscopic liver resection in a single institution. Br J Surg. 2009;96(3):274–9.
7. Buell JF, Cherqui D, Geller DA, O’Rourke N, Iannitti D, Dagher I, et al; World Consensus
Conference on Laparoscopic Surgery. The international position on laparoscopic liver
surgery: The Louisville Statement, 2008. Ann Surg. 2009;250(5):825–30.
8. Ciria R, Cherqui D, Geller DA, Briceno J, Wakabayashi G. Comparative short-term benefits
of laparoscopic liver resection: 9000 cases and climbing. Ann Surg. 2016;263(4):761– 77.
9. Huscher CG, Lirici MM, Chiodini S. Laparoscopic liver resections. Semin Laparosc Surg.
1998;5:204–10.
10. Belli G, Gayet B, Han HS, Wakabayashi G, Kim KH, Cannon R, et al. International
Consensus Group for Laparoscopic Liver Surgery. Laparoscopic left hemihepatectomy a
consideration for acceptance as standard of care. Surg Endosc. 2013;27(8):2721–6.
11. Dagher I, Gayet B, Tzanis D, Tranchart H, Fuks D, Soubrane O, et al. International
experience for laparoscopic major liver resection. J Hepatobiliary Pancreat Sci. 2014;21
(10):732–6.
12. Nitta H, Sasaki A, Fujita T, Itabashi H, Hoshikawa K, Takahara T, et al. Laparoscopy-assisted
major liver resections employing a hanging technique: the original procedure. Ann Surg.
2010;251(3):450–3.
13. Lin NC, Nitta H, Wakabayashi G. Laparoscopic major hepatectomy: a systematic literature
review and comparison of 3 techniques. Ann Surg. 2013;257(2):205–13.
14. Wakabayashi G, Cherqui D, Geller DA, Buell JF, Kaneko H, Han HS, et al. Recommendations for laparoscopic liver resection: a report from the second international consensus
conference held in Morioka. Ann Surg. 2015;261(4):619–29.
15. Hasegawa Y, Nitta H, Takahara T, Katagiri H, Baba S, Takeda D, et al. Safely extending the
indications of laparoscopic liver resection: When should we start laparoscopic major
hepatectomy? Surg Endosc. 2016 Jun 10 (Epub ahead of print).
16. Hasegawa Y, Koffron AJ, Buell JF, Wakabayashi G. Approaches to laparoscopic liver
resection: a meta-analysis of the role of hand-assisted laparoscopic surgery and the hybrid
technique. J Hepatobiliary Pancreat Sci. 2015;22(5):335–41.
17. Takahara T, Wakabayashi G, Nitta H, Hasegawa Y, Katagiri H, Takeda D, et al. Laparoscopic
liver resection for hepatocellular carcinoma with cirrhosis in a single institution. Hepatobiliary
Surg Nutr. 2015;4(6):398–405.